Effectiveness visual imagery techniques with Conventional Intervention on preoperative anxiety among children undergoing Surgeries in selected hospitals of Rajasthan - A Pilot study

 

Mohanasundari SK¹, Dr Padmaja A², Dr. Kirti Kumar Rathord³, Dr. Sunil Kothari⁴

¹PhD Scholar from INC, Faculty, College of Nursing, AIIMS Jodhpur, Rajasthan.

²Vice-Principal/Professor, College of Nursing, SVIMS, Tirupati., AP.

³Associate Professor, Dept of Pediatric Surgery, AIIMS, Jodhpur

⁴Dr. Sunil Kothari, HOD of Pediatric Surgery Department. Dr SNMC Jodhpur.

 

ABSTRACT:

 

 

INTRODUCTION:

Each year, more than 2 million children undergo surgical procedures. Children less than 15 years of age undergo approximately 2,159,000 surgeries annually in the United States, the reported incidence of preoperative anxiety in children is between 40% and 60%.¹⁹ The incidence of preoperative anxiety is reported to be 60- 65 % in children.¹

 

Children, their parents, and the nurses who care for them find the perioperative phase to be more stressful. Children may experience anxiety and fear about surgery, pain, separation from parents, unfamiliar surroundings, the unknown, unpleasant sensory stimulation, and loss of autonomy and control.² In the immediate preoperative period, which corresponds to 24 hours before surgery, discomfort is imminent for the children and their family, regardless of the type of surgery, outpatient or hospital approach and cultural context in which the child is inserted.^3,4 In addition, the susceptibility of the child, lack of understanding about the surgical procedure, unknown hospital environment, fear of physical injury, separation from their parents and feelings of sadness and punishment related to the fact that surgery is a scheduled procedure may contribute to such discomfort.^5,6

 

Anxiety is a common feeling among children in the preoperative period. As acute stress source, anxiety induces functional changes in the central nervous system, increases the deleterious effects on the child's body when associated with other perioperative stressors⁷ produces negative behaviors and high pain intensity scores in the postoperative period.^8. In addition, anxiety causes sleep disruption, nausea, fatigue, and inadequate responses to anesthesia and analgesia leading to higher costs for the health services and family.⁹

 

Increased anxiety, disturbances in eating and sleeping, as well as increased pain and analgesic use are some psychological problems that continue into the postoperative period¹⁰.

 

The literature revealed the effects of preoperative pediatric anxiety as contributory to the manifestation of numerous postoperative psychological behavioral changes such as feeding and sleeping problems, bedwetting, withdrawal and apathy, and these symptoms exist up to 2 weeks after surgery.¹⁰                 

 

A study concluded that Interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors post-surgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, visual imagery technique, acupuncture and the use of toys, games, video and cartoons to keep the child engaged during preoperative period.¹¹ for more serious problems, visual imagery is recognized as a form of treatment for anxiety, depression, learning disabilities, attention deficit disorder, and to help children prepare for surgery and procedures. Considered an alternative therapy for years, visual imagery is now gaining widespread acceptance in the medical and scientific world.¹² Visualization and imagery sometimes referred to as guided imagery techniques and these techniques involve the systematic practice of creating a detailed mental image of an attractive and peaceful setting or environment.

 

Visual imagery interventions addressing a variety of procedural outcomes have been met with success. There is plenty of evidence to show that visual imaginary technique used in health care settings can help calm patients. And given there are no side effects associated to these therapy it’s certainly a treatment worth trying. When this therapy visual combined with other modalities may be more effective than when presented alone, and that both can reduce the amount of pharmacological agents needed to control other physiological and psychological symptoms (e.g. pain and anxiety)¹³

Visual imagery techniques work to help people relax for several reasons. As is the case with many techniques, they involve an element of distraction which serves to redirect child’s attention away from what is stressing them and towards an alternative focus. The techniques are inturn a non-verbal instruction or direct suggestion to the body and unconscious mind to act "as though" the peaceful, safe and beautiful (and thus relaxing) environment were real.¹³

 

Nurses must have an understanding of the impact of surgery on children and families to help ease the stress of this difficult time. Present study focused on effect of visual imagery technique with conventional interventions in management of preoperative anxiety in children.

 

METHODOLOGY:

The effectiveness of VIT with conventional interventions on preoperative anxiety among children undergoing surgery was assessed through randomized controlled trial in UMAID Hospital.  Children aged between 4 to 12 years with mild to severe anxiety, who were planned for surgeries such as herniraphy inguinal hernia’s, explorative laporatomy with appendectomy for appendicitis, anorectalplasty for fistula, orchidopexy for undescended testis, cystoscopic valve ablation for PUVD, colostomy closure, open reduction for tibial fracture, incision and drainage for cyst in lower limb and incision and drainage of submandibular abscess were participant of this study. The Children undergoing emergency surgery, Mentally retarded children, Children with hearing impairment, Children undergoing ear surgeries and Children participating in any other clinical trial were not included in the study. This pilot study included (24 samples, 12 in each group) 1/3^rd of the total sample size of the main study. The sample was randomly distributed into 2 groups through computer-generated randomization allocation sequence. The type of randomization was block randomization using randomly varying block sizes to ensure equal numbers of participants into each group (Experimental group and control group)

 

The instrument/tools for the present study were structured standard scales, and tools contain four sections such as.^(14,15) section -1 was demographic variables which includes accompanying parent, age of the child, gender of the child, habitat, religion, socio economic status, duration of preoperative period, previous hospitalization and previous experience with anesthesia/Surgery. The level of parental anxiety was assessed through numerical visual anxiety scale (NVAS). NVAS was the standard scale which included scoring 0-10, interpreted as increasing level of anxiety with increasing score. Session-2 was physiological variables which includes pain, respiration and pulse rate.  Preoperative pain of the child was assessed through numerical visual pain scale (NVPS). As Pain and anxiety influences each other, it was assessed as secondary outcome; the NVPS was a standard scale with score of 0-10, the pain interpreted as increased severity with increased score. Child respiration, and pule rate also was monitored. Session-3 was standard rating scale-Hamilton Anxiety rating scale –it was first rating scales developed to measure the severity of anxiety symptoms, and is still widely used today in both clinical and research settings.  The scale contains 14 items and a series of symptoms, and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety) the 14 items were anxious mood, tension, fears, insomnia, intellectual, depressed mood, somatic (muscular) somatic (sensory): cardiovascular symptoms, respiratory symptoms, genitourinary symptoms, gastrointestinal symptoms, autonomic symptoms, and behavior at interview. With a total score range of 0–56, and each item scored on a scale of 0 (not present) to 4 (severe), Presence of any one symptom given in the each item (14items) scored for its severity. Session 4 was semi structured check list which included list of conventional intervention (such as parental presence, the use of toys, playing games, watching videos, cartoons, psychological support, storytelling, play therapy, preadmission tour ward and others interventions) that the child received.

 

Ethical permission was obtained from institutional ethical committee of Dr SN Medical College Jodhpur.

 

Data Collectionmethod and analysis: Preparative day -1 (on the day of admission) screened the child for anxiety with -Hamilton Anxiety rating scale (HAM-A) Children with no anxiety were excluded. children who meet the criteria was informed about the purpose of the study and Consent from children above 7 years and from guardian of children below 7 years was obtained. Samples randomly assigned to 2 groups. Obtained demographic data and level of pain, respiratory rate and pulse rate, Administer interventions 3 times a day until receiving preoperative sedative medication. It was informed that his or her role is to listen to the guided visual imagery audio for 15 to 30 minutes. The calm, quiet and comfortable environment was created in preoperative room. It was asked from the child to position comfortably and instructed to close the eyes. Head phone was placed on child ear. The prerecorded audio instructed the child to take slow and deep breaths to center the attention and calm them.  Encouraged to focus on the slow, in and out sensation of breathing or focus on releasing the feelings of tension from muscle, starting with the toes and working up to the top of the head the child to visualize the imagery. Child was encouraged to focus on the different sensory attributes present in the scene so as to make it more vivid in the mind.  Child was instructed to remain within the scene; touring its various sensory aspects for 15 to 30 minutes or until feels relaxed. Instructed the child to open eyes and then rejoin the world after few minutes.

 

After intervention children from both the group were reassessed for level of anxiety through HAM-A, reassessed for pain and vital signs, and all the samples were questioned and assessed for the conventional interventions received until receiving preoperative sedative medications. The data was compiled and analyzed with SPSS-16.

 

RESULT:

It was inferred from table-1 that the children who exposed to visual imagery technique showed improvement up to 42.4% and anxiety was reduced from  moderate to mild and no one had sever anxiety in pre and posttest.  Children who received conventional intervention suffered from mild to severe level of anxiety in post –test. Were in pretest it was 58.3% of them had mild anxiety and 41.7% children had severe to very severe anxiety.

 

It was inferred from the table-2 that the samples in experimental group (VIT) experienced 42.4% of reduction in anxiety level and control group the anxiety reduction rate was 2.89% only. The mean difference with the groups also showed high in experimental group (-6.5) when compared to control group (0.57). So it was inferred that VIT was effective in reducing preoperative anxiety level of the children.

 

Table 3 showed that there was a significant difference exists between pre and posttest anxiety level at P≤0.05 among children exposed to visual imagery technique (VIT), and there was no significant difference exists between pre and posttest anxiety level of the children at P≤0.05 among children exposed to conventional intervention alone. So the intervention (VIT) was effective in reducing preoperative anxiety level of the children

 

Table-4 shows that there was a significant difference exists in posttest anxiety level of the children undergoing surgeries and no significant difference exists in pretest anxiety level between the groups at p<0.05 level. So the intervention (VIT) was effective in reducing preoperative anxiety level of the children.

 

From table-5 it was inferred that anxiety level and accompanying person during preoperative period was significantly associated with anxiety level of the children in control group. And there was no significant associations exist between other demographic variables in both the groups at p<0.05 level. Figure 1 show that most of the parents have uncomfortable feeling about their child hospitalization and surgery.

 

From table-6 it was inferred that there was moderate positive correlation exists in experimental group (VIT) between pretest pain and preoperative anxiety, as well as between parental anxiety and pretest anxiety level of the children. There was moderate positive correlation exist between post-test pain and preoperative anxiety level of the children in control group.

 

 

Table-1: Frequency and percentage distribution of the samples in each group

Score	Interpretation	Frequency (%)
		Experimental group		Control group
		Pretest	Post test	pretest	Post test
No anxiety		0	0	0	0
Mild	<17	7 (58.3%))	12 (100%))	7 (58.3%))	5 (41.7%))
Mild to Moderate	17-24	5 (41.7%))	0	0	2 (16.7%)
Moderate to severe	24-30	0	0	0	3 (25%))
Severe to very severe	>30	0	0	5 (41.7%))	2 (16.7%))

 

Table-2: Pre – and posttest mean and standard deviation of the samples

 

Table-3: Paired/Dependent ‘T’ test.

Group	‘t’	‘P’ (<0.05)
Experimental Group (Virtual reality therapy-VIT)	5.14	0.00*
Control Group (Conventional intervention-CI)	0.18	0.86

Note:  *Asterisk indicate significant association at p<0.05 level.

 

Tbale-4: Unpaired/ Independent ‘t’ test between the conventional intervention and visual imagery technique

Between the group test	Independent “t” test	P values	Mean and SD		Mean Difference
			Control group	Experimental group
Posttest	2.724	.016*	19.08 ±12.12	8.83 ±4.78	-10.250
Pretest	0.958	0.355	19.67 ±14.88	15.33 ±4.86	- 4.33

Note:  *Asterisk indicate significant association at p<0.05 level.

 

Table-5: Frequency and percentage distribution of samples, Association between selected demographic variables with level of anxiety.

Demographic variables	Frequency (%)		Fisher’s exact  test
			X2	‘P’	X2	‘P’
			Experimental Group		Control Group
	Experimental Group	Control Group
1.  Accompanying parent a)  Mother b)  Father c)  Others	2 (16.7) 7 (58.3) 3 (25)	7 (58.3) 4 (33.3) 1 (8.3)	2.963	0.22	7.7763	0.01*
2.  Age of the child: a)  4 to7 years b)  7-10 years c)  10 to 14  years	3 (25) 7 (58.3) 2 (16.7)	4 (33.3) 6 (50) 2 (16.7)	3.23	0.470	4.314	0.086
3.  Gender of the child: a)  Male b)  Female	7 (58.3) 5 (41.7)	11 (92.7) 1 (8.3)	1.195	0.558	1.88	0.417
4.  Habitat : a)  Rural b)  Urban c)  Semi urban	9 (75) 3 (25)	3 (25) 9 (75)	1.024	0.523	1.024	0.523
5.  Religion: a)  Hindu b)  Muslim	9 (75) 3(25)	10 (83.3) 2 (16.7)	0.116	1.00	2.438	0.470
6.  Socio economic status of the family (per capita monthly income)) a)  Rs 5357 and above b)  Rs 2652 to 5356 c)  Rs 1570 to 2651 d)  Rs 812 to 1569 e)  Rs<811	1 (8.3) 3 (25) 4 (33.3) 3 (25) 1 (8.3)	0 4 (33.3) 5 (41.7) 2 (16.7) 1                     (8.3)	2.579	1.00	2.686	0.646
7.  Duration of  preoperative period a)  1  day b)  2 days c)  3 days d)  >3 days	0 8 (66.7) 1 (8.3) 3 (25)	5(41.7) 6 (50) 0 1                     (8.3)	1.115	1.00	4.784	0.072
8.  Previous hospitalization a) Yes b) No	2 (16.7) 10                  (83.3)	7(58.3) 5(41.7)	0.068	1.00	0.01	1.00
9.  Previous experience with anesthesia/Surgery a) Yes b) No	1 (8.3) 11(92.7)	5 (41.7) 5(58.3)	1.880	0.417	0.01	1.00

Note:  *Asterisk indicate significant association at p<0.05 level.

 

Figure-1: Level of parental anxiety in between the groups

 

Table-6: Correlation between Pre-operative pain and anxiety level of children in both the groups

Correlation	Experimental group		Control group
	‘r’	‘P’	‘r’	‘P’
Pre-test pain and anxiety level	0.503	0.096*	0.246	0.441
Post-test pain and anxiety level	-0.137	0.670	0.587	0.045*
Parental anxiety and pretest anxiety level of the children	0.616	0.033*	0.355	0.257

 

 

DISCUSSION:

In this present study children who exposed to visual imagery technique showed improvement up to 42.4% and anxiety was reduced to moderate to mild and no one had sever anxiety in pre and posttest.  Children who received conventional intervention suffered from mild to severe level of anxiety in post -test (41.7% mild, 16.7% moderate, 25% severe and 16.7% very sever anxiety). The percentage of effect was 42.4% and 2.89% in experimental and control group respectively. There was a significant difference exists in posttest anxiety level of the children undergoing surgeries and no significant difference exists in pretest anxiety level between the experimental group and control group at p<0.05 level. So the intervention (VIT) was effective in reducing preoperative anxiety level of the children. in this present study it was inferred that there was moderate positive correlation exist in experimental group (VIT) between pretest pain and preoperative anxiety, as well as between parental anxiety and pretest anxiety level of the children. There was moderate positive correlation exist between post-test pain and preoperative anxiety level of the children in control group.

 

The findings of this study supported by the study of  Lambert et al (1996)¹⁶ who examined the effect of hypnosis/guided imagery on the postoperative course of pediatric surgical patients. Similarly this study was supported by a study of Thomas MB (2003)¹⁰ et al who examined the effect of relaxation and guided imagery on autonomic nervous system.

 

CONCLUSION:

It was concluded that visual imagery technique are effective in reducing preoperative anxiety level of the children when combined with conventional intervention rather than conventional intervention alone. Visual imagery technique given especially just before or preoperative medication the child will experience very less anxiety or no anxiety and that could reduce the post-operative stay and improve outcome status of the child. Visual imagery technique should become part of preoperative intervention.

 

CONFLICT OF INTEREST:

No actual or potential conflict of interest.

 

ACKNOWLEDGEMENT:

My sincere thanks to MDRU team of SNMC Jodhpur. I thank the following research assistants who aided in data collection; Ms Hiteshi, Ms. Kavita, Ms Kiran, Ms Annu and Ms Shilpa.

 

SOURCES OF FUNDING:

Self-funded.

 

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Received on 19.02.2020          Modified on 20.03.2020

Accepted on 17.04.2020      ©AandV Publications All right reserved